Ophthalmology Cases (Pestana) Flashcards
A two year old has a huge, pedunculated lipoma hanging out from his right upper eyelid, and obstructing his vision on that eye.
What is the point of this vignette? - To remind you that the brain “learns” to see what the eyes see during early infancy (up to about age 7). If one eye can not see (any kind of obstruction) or the brain does not like what they see (double vision) the brain will refuse to process the image and that cortical “blindness” will be permanent (the concept of amblyopia).
Management: the problem has to be surgically corrected as early as possible.
A one year old child is suspected of having strabismus. You verify that indeed the corneal reflection from a bright light in your examining room comes from different places from each of his eyes.
What is the point of this vignette? - To remind you that the brain “learns” to see what the eyes see during early infancy (up to about age 7). If one eye can not see (any kind of obstruction) or the brain does not like what they see (double vision) the brain will refuse to process the image and that cortical “blindness” will be permanent (the concept of amblyopia).
Management: the problem has to be surgically corrected as early as possible.
A young mother is visiting your office for routine medical care. She happens to have her 18 month old baby with her, and you happen to notice that one of the pupils of the baby is white, while the other one is black.
What is it? – An ophthalmological and potentially life-and-death emergency. A white pupil (leukocoria) at this age can be retinoblastoma. This kid needs to see the ophthalmologist not next week, but today or tomorrow. If it turns out to be something more innocent, like a cataract, the kid still needs it corrected to avoid amblyopia.
Your distant cousin that you have not seen for years visit you and brag about their beautiful baby with “huge, shiny eyes”. They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture).
What is it? - Huge eyes in babies can be congenital glaucoma. Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue.
A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel “hard as a rock”.
What is it? - A classical description of acute glaucoma. Not the most common type (most are asymptomatic…but you can not write a vignette for those), but one that requires immediate Rx.
Management: An ophthalmologist is needed right away…but if you are put in a position to chose treatment, pick Diamox, pilocarpine drops or Mannitol.
A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye.
What is it? - Orbital cellulitis.
Management: Another ophthalmological emergency that requires immediate consultation, but if asked what to do, CT scan will be indicated to assess the extent of the orbital infection and surgical drainage will follow.
A frantic mother reaches you on the phone, reporting that her 10 year old boy accidentally splashed Drano on his face and is screaming in pain complaining that his right eye hurts terribly.
Management: We know that copious irrigation is the main treatment for chemical burns. The point of this vignette is to remind you that time is a key element. If the lady is instructed to bring the boy to the ER, his eye will be cooked to a crisp by the time he arrives. The correct answer here is to instruct the mother to pry the eye open under the cold water tap at home, and irrigate for about 1⁄2 hour before she brings the kid to the hospital. You will do more irrigation at the ER, remove solid matter, and eventually re-check pH before the kid goes home.
A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field.
What is it? - Retinal detachment. One or two floaters would not mean that. More than a dozen is an ominous sign, and that “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye.
Management: Another ophthalmological emergency. The retina specialist will use laser treatment to “spot weld” the retina back in place.
A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no other neurological symptoms.
Management: Another ophthalmological emergency…although little can be done for the problem. He has to get the ER instantly and it might help for him to breathe into a paper bag on route, and have someone press hard on his eye and release repeatedly.
A 55 year old man is diagnosed with type two diabetes mellitus. On questioning about eye symptoms he reports that sometimes after a heavy dinner the television becomes blurry and he has to squint to see it clearly.
What is it? - The blurry T.V. is no big deal: the lens swells and shrinks in response to swings in blood sugar…the important point is that he needs to start getting regular ophthalmological follow up for retinal complications. It takes 10 or 20 years for those to develop, but type 2 diabetes may have been present that long before it was diagnosed.
